TRAUMATO THE PELVIS (H ALAM, SECTION EDITOR)

Orthopedic Approach to the EarlyManagement of Pelvic Injuries

Michael J. Weaver & Marilyn Heng

Published online: 25 January 2015# Springer International Publishing AG 2015

Abstract High-energy pelvic fractures in trauma patientscause significant morbidity and mortality. A systematic ap-proach to the early evaluation and management of these pa-tients leads to improved outcomes. The initial care of patientswith a displaced pelvic fracture and hemodynamic instabilityshould focus upon three areas: 1) resuscitation, 2) bony stabil-ity, and 3) hemorrhage control. Aggressive resuscitation withblood products and clotting factors is paramount. The initialreduction of the pelvic ring and temporary stabilization can beachieved through the use of pelvic sheeting or binder placed inthe field or trauma bay. Urgent surgical stabilization with ex-ternal or internal fixation is often required. Hemorrhage con-trol can be achieved through pelvic packing and/orangioembolization. The initial management of displaced pel-vic fractures is multidisciplinary and should involve close col-laboration between trauma surgery, orthopedic surgery, anes-thesia, and interventional radiology.

Keywords Pelvic fracture . Polytrauma . Resuscitation .

Hemorrhage . Pelvic packing . Retroperitoneal packing .

Angiography . Pelvic binder

Introduction

High-energy displaced pelvic fractures represent a significantcause of mortality and morbidity in the trauma patient. Mor-tality in trauma patients with a pelvic fracture has been report-ed to range from 5 to 20 % in all-comers [1, 2], with higher

rates in patients with concomitant hemodynamic instability oropen injury [2–4].

An understanding of the mechanisms of injury that lead topelvic fractures is useful to guide treatment and understandpatterns of injury and causes of mortality. While fractures thatresult from a head-on impact are associated with significantblood loss, side-pact injuries are often seen in conjunctionwith head and abdominal injuries [5, 6].

The initial management of displaced pelvic fractures ismultimodal and should involve close collaboration betweentrauma surgery, orthopedic surgery, anesthesia, and interven-tional radiology [7, 8]. The immediate care of patients withunstable pelvic fracture should be focused on three primaryareas: resuscitation, bony stability, and hemorrhage control.

Evaluation

Patients with a suspected pelvic fracture should be managedaccording to the principles of Advanced Trauma Life Support(ATLS) [9]. Of primary concern is establishing and maintain-ing a viable airway while maintaining C-spine control, evalu-ation of the patient’s breathing with maintenance of adequateoxygenation, and protection of the patient’s circulation withassessment for hemorrhage and adequate control of bleeding.

During the primary survey, the stability of the pelvis shouldbe assessed [9]. Although physical examination alone withoutfluoroscopy is not sensitive to detect minor instability, thepresence of gross instability portends a severely unstable frac-ture that may be associated with significant bleeding. Thestability of the pelvis is assessed by firmly grasping the iliacwings and assessing for any motion by attempting to push andpull them apart and together [10•]. A significant leg lengthdiscrepancy in the absence of an obvious long bonefracture may indicate a vertically unstable and displacedpelvic fracture.

This article is part of the Topical Collection on Trauma to the Pelvis

M. J. Weaver (*) :M. HengDepartment of Orthopaedic Surgery, 75 Francis Street, Boston,MA 02115, USAe-mail: MWEAVER@research.bwh.harvard.edu

Curr Trauma Rep (2015) 1:16–25DOI 10.1007/s40719-014-0005-4

During the secondary survey, the examiner should fullyexamine the pelvis. Care should be taken to look for openwounds around the pelvis and perineum that may indicate anopen injury (Fig. 1). All patients should have a digital rectalexamination, and female patients should have a vaginal exam-ination to assess for lacerations that could communicate with apelvic fracture. Open pelvic injuries are associated with mor-tality of up to 50 % [11•, 12, 13]. Antibiotics including a first-generation cephalosporin and a broad-spectrum antibioticwith gram-negative coverage such as gentamycin should begiven promptly to reduce the risk of infection [14]. Largeperineal or rectal injuries may necessitate a diverting colosto-my to avoid contamination of the wounds [15, 16].

The presence of blood at the urethral meatus may suggest aurethral injury, and in these cases, a retrograde urethrogram(RUG) should be obtained prior to Foley catheterization [17].Once passed, the presence of blood in the urine may indicate abladder injury, and a cystogram should be performed [18, 19].

Obtaining an AP radiograph of the pelvis in the trauma bayis essential in the treatment of a hemodynamically unstablepatient with a suspected pelvic fracture. This radiograph aloneis enough to direct the initial management of displaced pelvicring injuries. Some authors have advocated deferring an APpelvis radiograph if the suspicion of a pelvic fracture is lowand the patient is stable enough for computed tomography ofthe abdomen and pelvis [20–22]. However, in cases where apelvic ring injury is likely or the patient is hemodynamicallyunstable, an AP plain radiograph should be taken as part of theinitial primary survey evaluation to allow for the initiation oftreatment as soon as possible.

The initial management of a displaced pelvic fracture re-quires only an AP radiograph; however, definitive treatmentmost often requires a CT scan to better delineate the posteriorinjury.

Consultation with the orthopedic trauma service should beinitiated as soon as a pelvic fracture is suspected. The success-ful evaluation and management of these injuries requires amultidisciplinary approach [7, 8].

Classification

While there are numerous classification systems used to de-scribe pelvic fractures, the most common is the Young andBurgess system [23]. This classification system is based uponthe mechanism of injury that leads to predictable patterns ofinjury and displacement [6, 23]. It is useful in describing in-juries and also to help guide both initial treatment and defin-itive fixation (Fig. 2).

Anteroposterior Compression (APC). This pattern of injuryresults from a direct blow to the anterior pelvic ring or occa-sionally from an external rotation force applied to one lowerlimb. The common term for this type of injury is “open book”as the anterior pelvic ring separates and opens, while the pos-terior ligamentous complex of the sacroiliac (SI) joints remainsintact, allowing the pelvis to hinge open. APC 1 injuries in-volve only minor (<2.5 cm) pubic diastasis. APC 2 injuriesinvolve more pubic diastasis (>2.5 cm) but have intact posteriorSI ligaments. APC 3 injuries involve significant pubic diastasisand the complete disruption of the posterior SI ligaments. APCinjuries permit the expansion of the pelvic ring resulting in asignificant increase in pelvic volume. They are often associatedwith significant hemorrhage, which is the most common causeof death in patients with displaced APC injuries [6].

Lateral Compression (LC). This is the most common injurypattern. It often results from a side-impact motor vehicle colli-sion. A laterally directed force causes the internal rotation of theinjured hemipelvis with a reduction in pelvic volume. LC 1injuries involve superior and inferior pubic ramus fractures with

Fig. 1 A patient with a large perineal laceration that communicates withthe rectum. A diverting colostomywas required to prevent stool soiling ofthe wound Fig. 2 The Young and Burgess Classification of pelvic fractures

Curr Trauma Rep (2015) 1:16–25 17

a sacral ala fracture that is often incomplete. LC 2 injuriesinvolve superior and inferior pubic ramus fractures and afracture/dislocation of the SI joint on the involved side. LC 3injuries involve a lateral compression-type injury on one side,with an APC-type injury on the contralateral side, and are com-monly called “windswept” pelvic fractures. Significant hemor-rhage from these injuries is possible, although less common,and is typically the result of arterial injury. The most commoncauses of mortality in patients with LC-type fracture patternsare associated injuries such as head and abdominal injuries [6].

Vertical Shear (VS). These injury patterns result from fallsfrom a significant height but also occasionally from motorvehicle collisions [6]. The injury can be either ligamentousor bony or a combination of both. In either case, the hallmarkof this injury is the proximal migration of one hemipelvis.Vertical shear fractures are typically very unstable. They oftenrequire the placement of skeletal traction to partially reducethe displaced hemipelvis prior to definitive management.

CombinedMechanism. These rare injuries are patterns that donot fit into the other categories. Associated acetabular frac-tures are often present. These injuries are best described ana-tomically, and treatment is tailored to the specific pattern ofinjury and displacement.

Management

The management of displaced pelvic fractures should be mul-timodal and protocol driven. It has been shown that the use ofaggressive management protocols can reduce transfusion ratesand mortality [24, 25••, 26, 27].

The initial management of displaced pelvic fractures inhemodynamically unstable patients involves three domains(Fig. 3):

1. Resuscitation2. Bony stability3. Hemorrhage control

These three domains do not need to be addressed in se-quence but, in practice, can be addressed in parallel.

Resuscitation

The pelvic cavity and retroperitoneal space represent a largepotential space for exsanguination in the trauma patient. Ca-daveric study has shown that the potential volume of theretroperitoneum with an intact pelvis is approximately 5 L,

and with the disruption of the bony anatomy, such as withan open-book pelvic fracture, several times, the total bodyblood volume can be lost into this expanding space [28].The proper resuscitation of the trauma patient with a pelvicinjury is vital to their survival.

Resuscitation begins in the prehospital phase, and usually,by the time a hemodynamically unstable pelvic fracture pa-tient arrives in the trauma bay, they have had an adequate trialof fluid resuscitation with 1 L crystalloid fluid as per the mostrecent edition of the Advanced Trauma Life Support (ATLS)protocol [9]. The goal of resuscitation is to prevent the devel-opment of the lethal combination of acidosis, hypothermia,and coagulopathy. The prevention of hypothermia is an im-portant aspect of resuscitation. Judicious exposure and re-membering to re-cover the patient after the examination ofthe pelvis is key but often overlooked.

Permissive hypotension is a term used to denote theacceptance/target of a lower blood pressure in trauma patientsuntil hemorrhage control is achieved. Its premise is inavoiding the development of a dilutional coagulopathy in thepatient. There have been no experimental or observationalstudies focused on permissive hypotension in pelvic fracturepatients specifically. A 2011 randomized controlled trial oftrauma patients with hemorrhagic shock assigned patients re-quiring emergent surgery to a low mean arterial pressure (tar-get MAP 50 mmHg) treatment arm vs a control arm of stan-dard resuscitation to a target MAP of 65 mmHg [29••]. Theirpreliminary results show significantly lower mortality in theearly postoperative period for patients managed with a hypo-tensive goal. The risk of coagulopathy in the lowmean arterialpressure group was lower as was the severity of coagulopathyif it did occur [29••]. There is concern regarding the use of

Fig. 3 Three areas of focus during the acute management of pelvicfractures

18 Curr Trauma Rep (2015) 1:16–25

permissive hypotension in certain populations, specificallypatients with head injury and elderly patients who have ahigher likelihood for coronary artery disease—both of thesetypes of patients can commonly present with an associatedpelvic fracture. A recent retrospective study of theTraumaRegister DGU in Germany looked specifically at per-missive hypotension in elderly trauma patients [30]. Therewas no difference in mortality seen between elderly patientstreated with preclinical fluid resuscitation of ≤1 L fluid andthose treated with >1 L fluid resuscitation. It also appearedthat patients in the low volume resuscitation group had ashorter prothrombin ratio (analogous to INR) indicating lesscoagulopathy. Thus, restraint in fluid resuscitation even inelderly patients may be safe.

Current literature emphasizes the importance of the earlyuse of blood and blood products in resuscitation efforts. Theconcepts of “damage control resuscitation” first developedthrough the military experience in Iraq and Afghanistan haveled to the general acceptance of a 1:1:1 plasma:platelets:RBCstransfusion protocols [31, 32]. These protocols have been tra-ditionally utilized in the context of the massively transfusedpatients (RBC requirement of ≥10 units in 24 h); however,more recent studies have begun to apply these principles toall trauma patients requiring transfusion. In a 2013 study of905 trauma patients, the Prospective, Observational, Multi-center, Major Trauma Transfusion (PROMMTT) investigatorsdemonstrated an association of decreased mortality within thefirst 24 h with higher plasma:RBC transfusion ratios and with-in the first 6 h with higher platelet:RBC transfusion ratios [33].

Age, systolic blood pressure, shock on arrival, revised traumascore (RTS), and base deficit have been identified through ret-rospective analysis as predictors for transfusion in pelvic fracturepatients [2]. The influence of fracture pattern on transfusionrequirement has been examined. Traditionally, APC 3 fracturesas classified by the Young-Burgess Classification have beenshown to require the greatest amounts of fluid resuscitation inthe first 24 h [23]. In the modern era of resuscitation, both theYoung-Burgess Classification and the Tile Classification for pel-vic fractures have been shown to be predictive of transfusionrequirements in general [34, 35]; however, fracture pattern alonecannot solely indicate which patients require transfusion or notas only 40–60% of pelvic fractures with bony instability requiretransfusion, and conversely, some pelvic fractures deemed skel-etally stable will require transfusion [36].

Bony Stability

Urgent reduction and temporary stabilization of displaced pelvicfractures is paramount. Displaced pelvic fractures are associatedwith the disruption of the rich venous plexus in the presacral areaand pelvic floor [37]. Fractured bone surfaces are also a signif-icant source of blood loss. Injury patterns can increase the pelvic

volume such that the hemorrhage of the multiples of the circu-lating blood volume into the true pelvis and retroperitonealspace can occur [28]. Furthermore, displaced pelvic fracturesare most often unstable, and themovement of fracture fragmentscan disrupt clots that form as a response to abate hemorrhage.The reduction of displaced pelvic fractures reduces the pelvicvolume, re-opposes fractured bone surfaces, and allows for theformation of clot to reduce bleeding.

The easiest and least invasive way to reduce the pelvicvolume and temporarily stabilize the pelvis is with circumfer-ential sheeting or the application of a pelvic binder [38•, 39].Emergency personnel can perform this procedure in the field,or it can be performed upon initial presentation in the traumabay if a displaced pelvic fracture is suspected [38•]. It is ourrecommendation that a sheet/binder be applied in all cases ofsuspected pelvis fracture and then its need be re-assessed afterthe primary survey and the evaluation of the pelvic radiographand fracture pattern.

Care should be taken to ensure that the sheet or binder iscentered squarely over the greater trochanters and securelytightened (Fig. 4). Postreduction radiographs are important togauge the reduction and effectiveness of the sheet or binder.There is some controversy as to the efficacy of using sheet orbinder stabilization in the setting of lateral compression inju-ries; however, the risk is likely very low, and unless the fracturepattern is known, sheeting or a binder should be employed.

If a sheet or binder is applied to a patient with a suspectedpelvic fracture, but radiographs reveal no injury, an additional setof films should be taken immediately following the removal ofthe binder or sheet to ensure that a purely ligamentous injurywasnot reduced by the sheet and missed on the initial radiographs.To avoid the complication of pressure ulcers and skin break-down, a binder or sheet should not be left on for more than 24 h.

External fixation is the most commonly employed tech-nique for achieving temporary reduction and stabilization ofdisplaced pelvic ring injuries. The technique involves theplacement of Schanz pins into the innominate bones of the

Fig. 4 A circumferential pelvic sheet or binder should be centered on thegreater trochanters and cinched tight. Additionally, the toes should betaped together to help avoid the external rotation of the injured limband hemipelvis

Curr Trauma Rep (2015) 1:16–25 19

pelvis [40]. The pins are then used to directly manipulate thefractured fragments, and an external frame is then constructedto maintain this reduction. Pins can be safely placed into theiliac crest without the aide of C-arm fluoroscopy (Fig. 5).Supra-acetabular pin placement is also useful, although thistechnique requires the use of C-arm fluoroscopy to ensure safepin placement.

External fixation is typically used to stabilize the bonypelvis and affects an approximate reduction of the bone frag-ments [40]. In many cases, once the patient has been stabi-lized, the frame can be removed and the pelvis can be repairedthrough an open approach [41]. This allows for a direct reduc-tion of the fracture fragments and avoids the problems associ-ated with long-term external fixation such as pin site infectionand a bothersome contraption on the patient [42]. Occasion-ally, the external fixator is used for definitive fixation, and inthese cases, it is often left in place for 8–12 weeks.

While the external fixation of the iliac wings is excellent atcontrolling the anterior pelvic ring and managing fracture pat-terns that involve primarily anterior displacement or “openbook”-type injuries, injuries that involve the significant dis-placement of the posterior pelvic ring are often poorly con-trolled with external fixation alone [43, 44]. External fixatorpins are placed into the anterior ring, and given the long leverarm between the posterior ring and the anterior frame, there islittle ability to directly control the posterior pelvic ring. Inthese situations, the use of a “C-clamp” is advantageous. Thisdevice involves the placement of two pins, one through theouter table of each ilium, in the area of the sacroiliac joint. Anexternal frame then allows direct compression across the pos-terior aspect of the pelvis (Fig. 6) [45, 46].

Some authors advocate for urgent or emergent open reduc-tion and internal fixation of displaced pelvic ring injuries [47].This is particularly useful in the setting of anteroposteriorcompression (APC) injuries. The surgical approach is simple,and the reduction and fixation of these injuries can often be

Fig. 5 External fixation involves the placement of pins into theinnominate bones (a). In this case, the pins are placed into the iliac crest(b). An anterior frame is then constructed to maintain the reduction of thepelvis. This frame can be adjusted to allow for access to the abdomen ifrequired. External fixation provides the excellent control of anteriordisplacement but does not allow for reduction or stabilization of injuriesthat involve significant posterior displacement

Fig. 6 The C-clamp is useful in controlling fractures with significantposterior displacement (a). In this case, specialized pins (b) are placedat the level of the sacroiliac (SI) joint, and direct manipulation andcompression of the posterior pelvis is possible

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accomplished as fast as external fixation. Often, this treatmentstrategy is combined with retroperitoneal packing (Fig. 7).Depending on the quality of the reduction and the method ofinternal fixation, this technique can be used as the definitivemode of fixation or can be revised if required during subse-quent visits to the operating room.

Hemorrhage Control

One of the more recent controversies in the early orthopedicmanagement of pelvic fractures in the trauma patient has beenthe algorithm for management of the “exsanguinating,” i.e.,hemodynamically unstable pelvic fracture patient.

Traditionally, advocacy for the use of angioembolization hasbeen strong in North America, whereas the use of surgicalpelvic packing is more popular in Europe.

Surgical pelvic packing consists of preperitoneal pelvicpacking. This may be done through a limited Pfannenstiel in-cision, and packing within the retroperitoneum is performedwithout the violation of the peritoneum. Care must be takento ensure the packs are placed inferior, down into the true pel-vis, such that they can tamponade the presacral area and pelvicfloor. It is important that the bony stabilization of the pelvis isobtained before preperitoneal packing to allow the packing toachieve a tamponade against the pelvic rim. This technique isexplicitly different from the older methods of surgical pelvicpacking which frequently occurred transperitoneal through alaparotomy incision and which had suboptimal results [48, 49].

Within North America, there has been recent increasedinterest in preperitoneal packing for hemodynamically unsta-ble pelvic fracture patients before angioembolization. Onecase series at a center that has incorporated preperitoneal pack-ing into their treatment algorithm since 2004 has reported theirresults noting that preperitoneal packing has been effective inthe control of hemorrhage in hemodynamically unstable pel-vic fracture patients [50]. During their 5.5-year study period,no pelvic fracture patients died from acute hemorrhage. The

Fig. 7 Preoperative (a) and postoperative (b) radiographs of a patientwith anAPC 3 injury. Note the initial pubic symphysis diastasis and right-sided SI joint widening. The patient was initially treated with openreduction and internal fixation with retroperitoneal packing. Theanterior pelvic ring has been reduced, but there is still the subtlewidening of the SI joint that will require definitive treatment with a SIscrew. Multiple packs are seen within the true pelvis

Fig. 8 The angiography of a patient with an unstable pelvic fracture.Note the extravasation of contrast around the branches of the rightinternal iliac artery and superior gluteal artery (arrows)

Curr Trauma Rep (2015) 1:16–25 21

use of angioembolization secondarily was required in 13 % ofthose patients who underwent pelvic packing.

Indications for angiographic embolization have includedcontrast extravasation on arterial phase CT scans and ongoinghemodynamic instability despite fluid and blood resuscitation(Fig. 8). Fracture pattern alone does not necessarily aide indetermining the utility of angiography [51]. The efficacy ratesof arterial embolization for pelvic fracture have been reportedfrom 81 to 100 % with the need for repeat embolization inapproximately 10 % of cases [52].

There have been no randomized controlled trials evaluatingangiographic embolization vs preperitoneal pelvic packing inthe literature. One observational before-and-after cohort studyexamined the outcomes after a treatment algorithm shift fromemergency angiographic embolization to preperitoneal pack-ing [53••]. This study demonstrated shorter median time tooperating room compared to mean time to angiography suite.There was a significant decrease in blood transfusion require-ment in the immediate 24 h after intervention in the pelvicpacking group. No significant differences in mortality or com-plication rate were observed between the two treatment pro-tocols. Most current studies in the literature comparing

angiography vs operating room (OR) do not necessarily ad-dress the question of comparative effectiveness—in somestudies, the decision to go to the OR first was made on thelikelihood of other sources of bleeding (i.e., +FAST), so de-spite the article title, they do not really compare equivalentsituations [54]. The disadvantages of a management protocolreliant solely on angioembolization include delays due to therelative unavailability of the angiography suite/interventionalradiologist and that it does not address venous pelvic bleeding.The contribution of venous hemorrhage to pelvic fracture ex-sanguination has been recognized in previous cadaveric andclinical studies [55–57].

Lastly, the use of tranexamic acid (TXA) to control hem-orrhage in pelvic fractures remains controversial. Tranexamicacid use during elective arthroplasty surgery has been shownto reduce transfusion rates [58]. There are no studies to dateregarding the use of tranexamic acid in pelvic fracture pa-tients. The CRASH-2 trial examined the effects of TXA intrauma patients with or at risk of significant bleeding [59].Their results showed a decreased risk of early all-cause mor-tality in patients who received TXAwithin 8 h of their injury.There was a statistically significant decrease in mortality due

Fig. 9 Practical protocol to manage pelvic fractures in hemodynamically unstable patients utilizing retroperitoneal packing for hemorrhage control

22 Curr Trauma Rep (2015) 1:16–25

to bleeding; however, TXA did not appear to make any dif-ference in transfusion requirements between the groups. Thus,a mechanistic explanation of the effect of TXA still remains tobe elucidated and tempers its undisputed adoption into thetreatment algorithm for bleeding pelvic fracture patients.

Practical Protocol

The protocol we utilize at our institutions is similar to that firstdescribed by Cothren et al. [24]. We prefer the use of retro-peritoneal packing to control pelvic hemorrhage (Fig. 9). Pa-tients with significant pelvic injury who fail to respond to2 units of packed red blood cells are taken for emergent pelvicstabilization and retroperitoneal packing. Patients with a sig-nificant pelvic fracture but who respond to blood products aretaken either to angiography or to the surgical intensive careunit for close monitoring, and their pelvic fracture is stabilizedon a semi-urgent basis.

While we prefer the use of retroperitoneal packing, mostcenters in the USA favor a treatment strategy that focuses onangiography.

Conclusion

High-energy displaced fractures of the pelvis are a significantsource of morbidity and mortality. The management of thesecomplex injuries requires cooperation between the trauma andorthopedic surgeons. In patients with displaced pelvic ringinjuries and hemodynamic instability, attention should be fo-cused on aggressive resuscitation of the patient, early stabili-zation of the bony injury, and hemorrhage control througheither angiography or retroperitoneal packing.

Compliance with Ethics Guidelines

Conflict of Interest Michael J. Weaver and Marilyn Heng declare thatthey have no conflict of interest.

Human and Animal Rights and Informed Consent This article doesnot contain any studies with human or animal subjects performed by anyof the authors.

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